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Orthodontic Treatment with the Invisalign Appliance

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Orthodontic Treatment with the Invisalign Appliance How Successful is Invisalign for How Successful is Treatment of Anterior Open Bite and Invisalign for Treatment of Deep Overbite? Anterior Open Bite and Agenda Pre Deep Overbite? I. Mild to moderate Anterior Open American Association of Bite Orthodontists Annual Meeting II. Mild to moderate Deep Overbite Philadelphia, PA Post May 5, 2013 Robert Boyd DDS, MEd Fred West Endowed Professor & Chair Department of Orthodontics Arthur A. Dugoni School of Dentistry 8 years post University of the Pacific Long-Term Stability of Mild to moderate Anterior Open Bite Treated with Clear aligners I. Mild to moderate Anterior Open Bite Agenda 1. Brief review of literature with conventional fixed 1. Brief review of literature with conventional fixed treatment , orthognathic surgery, Micro implants (MI) treatment, orthognathic surgery, Micro implants and Invisalign in regard to Stability (MI) and Invisalign 2. Is open bite a health related functional issue? 3. Case reports (non-extraction and extraction) -Based on 42 consecutive patients -1 to 9 yrs post retention –no orthognathic surgery or Micro implants (will show 14 today) * For more information refer to Align Technology’s open bite video available at Aligntech Institute of Invisalign.com Long-Term Stability of Anterior Open Bite Treatment How stable is posterior intrusion with micro with Conventional fixed appliances implants to close an open bite? Recent fixed studies–Smithpeter & Covell AJODO Beck et al. (Oct. 2010) AJODO –Some skeletal (2010) 137:605-14 –Zuroff et al AJODO and dental relapse (17 %) in first year post- (2010)137:302-8 –Reemers et al (2008) Orthod treatment, but good stablity after 3 years Crainofac Res 11:32-42 Deguchi et al. (April 2011) AJODO -2 year post Conclusions: comparison of MEAW (Kim) to MI’s and bone . Relapse is frequent (40 - 80%) plates (minor relapse) . Associated with increased mandibular plane angle -More relapse with MEAW than plates or MI’s . Anterior tongue position may be most important variable for relapse . Tongue habit reminders (MFT) are helpful But what if patient declines MI’s or plates? (repositioning of tongue posteriorly) 1 Palatal MI and lower buccal MI’s used for anchorage to intrude and retract posterior teeth to close an anterior open Pre vs post (MI Case treated by Cheol Ho Paik and Judie bite and bimaxillary protrusion Woo , Seoul, Korea) -Pretreatment Pre vs post -Posttreatment A B 2 years post-good stability with use of MI after Does Orthognathic surgery provide first year stability of open bite correction? Studies show that for long term results (< 2 yrs retention), that if positive overbite is a main goal then 35 % to 52% of patients will not have positive overbite • -Also, patients may not accept surgery 2 Can Invisalign treated patients have Long-Term Stability of Mild to moderate Anterior acceptable long-term stability of anterior Open Bite Treated with Clear aligners open bite? Agenda 2. Is open bite as a functional health related issue? -Only case reports - Boyd & Vlaskalic . Seminars in Orthodontics, Vol. 7 #4: 274-293. 2001 - Boyd et al. Journal of the California. Dental Association 34;793-805, 2006 - Boyd Journal of Clinical Orthodontics 41:525-547,2007 Long-Term Stability of Mild to moderate Anterior Open bite can frequently be a functional Open Bite Treated with Clear aligners health related issue Agenda -Leads to excessive wear of posterior teeth due to loss 3. Case reports (non-extraction vs extraction) of anterior contact and resulting lack of anterior -Based on 42 consecutive patients -1 to 9 yrs disclusion post retention –no orthognathic surgery or -Less efficient mastication Micro implants Does Invisalign have better long-term stability of anterior open bite? Phase I –Thumb habit treatment Pre -7 year old with thumb and tongue habit Phase II –full fixed appliances Pre Post Phase I –thumb habit stopped Post Phase II –narrow laterals will be bonded – shallow overbite 3 One year post- Upper laterals restored but open bite develops –Decision to use Invisalign Final aligners fit well CR 6 months Post Invisalign 2 years post treatment -good stability 11 year follow-up of open bite Mild extrusion (< 2mm) with force pushing against attachment CR Pre-tx 10 months -Extrusive force occurs from center of rotation with tipping and rotational movements (relative extrusion) 13 months 4 Superimposition -common finding is How does Invisalign close the anterior open no opening of mandibular plane angle bite? (my hypothesis) Increased bite force on posterior teeth due to aligner thickness and arc of closure Pre Pre=solid line Post =dotted lines Post How does Invisalign close the anterior open How does Invisalign close the anterior open bite? (my hypothesis) bite? (my hypothesis) Increased bite force on posterior Increased bite force on posterior teeth due to aligner thickness teeth due to aligner thickness This creates an intrusive force on This creates an intrusive force on the posterior teeth the posterior teeth Then incisors are slowly extruded with no eruption of molars Tongue is also blocked out during treatment and may move distally 5 Pre - Edge to edge bite with narrow arches High mandibular plane angle and long lower (Does posterior expansion tend to open rd bite in the anterior?) 1/3 facial height Measures value norm SNA 74 82 SNB 72 80 ANB 2 2 WITS 0 0 FMIA 56 65 FMA 35 22 IMPA 89 90 SN-GoGn 43 33 U1-SN 98 102 U1-NA (°/mm) 23/7 22/4 L1-NB (°/mm) 28/8 25/4 IIA 126 130 POG-NB 3 2 Pre , post. and 1 yr post Pre , post. and 1 yr post Pre (red) vs post (blue) Six years post No change in mandibular plane angle 6 . Pre – Mild open bite treatment with Six years post posterior crossbite -Previous fixed tx No contact of incisors Pre vs post – treatment Pre–Normal skeletal relationships -Needed more deepening of overbite Measures Value Norm 81 78__ SNA (º) 80.7 82 3 104 SNB (º) 77.9 80 ANB (º) 2.9 2 Wits (mm) -3 -1 140 FMIA (L1-FH) (º) 56.9 65 1 FMA (MP-FH) (º) 25.2 25 21 120 6 IMPA (L1-MP) (º) 97.9 95 37 SN-GoGn(º) 37.4 33 98 -1 U1 - SN (º) 104.5 102.8 U1 - NA (º/mm) 23.7°/5.9mm 23/4 L1 - NB (º/mm) 33.2°/10mm 25/4 IIA (º) 120.2 130 Pog - NB (mm) -1.4 2 Superimposition 3 years post treatment (No change in mandibular plane angle) –diastema opened but overbite was stable Initial Final 7 Pre -planned for implant to replace # 29 -8 mm space is needed Pre, post and 3 yr retention Would fixed appliances to upright molars in an open bite cause some extrusion and increase the anterior open bite? Comparison –Note closure of open bite Pre vs post –Note increased space for implant Comparison of pre and post for #29 to a premolar sized crown (3.5 to 8 mm) 8 Superimposition 2 yrs post ortho -good stability of open bite -No opening of mandibular plane angle Initiall Final Posterior crossbite and moderate anterior open bite Treatment with 4 mm crowding and protrusion -steep mandibulat plane Pretreatment 11 months 19 months Post 32 months Pre vs post 4 years post treatment Pre Post 9 8 years post Class I open bite with posterior crossbite -history of two previous fixed treatments final Pre, 18 months and post 4 yrs post 10 Pre –Class II subdivision right, anterior edge to edge with posterior crossbite and high canines - Class II unilateral elastics used with Invisalign Post Andrea A. - New G3 hooks make treatment much easier for Class II elastics One year post Drag and drop feature on new software Button Cutout Mesial Hook Pre - Class II moderate open bite and severe How well do new precision hooks work? occlusal wear (Had prior ortho twice) Very well so far with some exceptions: -Short clinical crowns or short aligners = little retention and “lift off “ esp. with opening Solution is to make sure the clinical crown is not cut back (good impression) on ClinCheck and add attachments for retention on adjacent teeth Or just use buttons 11 Post - Increased clinical crown lengths 1 Year Retention - Left side has posterior open bite Pre, post and 1 year Superimposition Class I open bite with crowding treated with premolar -Note continued closure of mandibular plane angle extractions and 8 months of segmental fixed Pre 14 months Initial 30 months Final 24 months 1 year retention: Pre, during and post 12 8 years post Pre Post Pre –Anterior open bite with impacted canines -Ortho treatment with extraction of # 6 & 11 At transfer to me –2 years of up and down elastics to and lower first premolars close bite -Tx plan: Remove appliances, stop elastics and let settle for 6 months Pre-After settling vs Post Invisalign 1 year post -No additional RR Nikki A. 13 . Pre vs post - Tx Invisalign with premolar extractions and lower fixed segments Pre Post Superimpositions Pre vs 30 months post Initial Final Pre 2 ½ years post –Invisalign with premolar extractions 14 Initial Ceph *Chinese norm Initial Panoramic Xray _note lack of root parallelism –makes Invisalign more difficult Measures Value Norm* SNA 82 82 SNB 77 79 ANB 5 3 Wits Appraisal -4 0 FMA (MP-FH) 34 22 FMIA (L1-FH) 53 57 IMPA (L1-MP) 93 93 MP - SN 43 32 U1 - SN 95 102 U1 - NA (º/mm) 13 / 2 24 / 5 L1 - NB (º/mm) 33 / 10 27 / 6 IIA 129 126 Pog - NB -1 2 Mild class II, steep mandibular plane and open bite 30 months –Place lower fixed for 5 months due to tipping into extraction sites Pre and Pre vs 6 months post 2 years post 15 Severe open bite with crowding and one Severe skeletal –Significantly increased mandibular premolar extraction plane angle and long lower third facial height Pre vs post Measures value norm SNA 73.5 82 SNB 69.0 80 72 ANB 4.5 2 __68 4 97 WITS -0.4 0 FMIA 52 65 133 FMA 49.6 22 28 61 -4 123 IMPA 78.4 90 Pre Post -1 78 SN-GoGn 59.6 33 2 Note how healthy the U1-SN 98.6 102 gingival tissue remains U1-NA (°/mm) 25.1/6.3 22/4 L1-NB (°/mm) 27.1/7.3 25/4 (Published in JCO IIA 123.4.
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